MEDICARE: BENJAMIN RUSSELL BACH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA11467	TX

General Provider Information

NPI Number	:	1346750064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN RUSSELL BACH PA

Provider Business Mailing Address
First Line	:	13025 PRELUDE DR
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75035-2224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7062 HIGHLANDS LN
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-0590
Country	:	US
Telephone Number	:	903-483-1090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2017
Last Update Date	:	10/08/2017

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